Conference Coverage

Reduced sedation during ventilation lowered ventilator-associated events

Key clinical point: Reducing ventilated patients’ sedation time through a nurse- and respiratory therapist–led opt-out protocol reduces the risk of ventilator-associated events.

Major finding: Protocol implementation was associated with a 37% decrease in VAE risk.

Data source: A multicenter quasi-experimental open-label study of 3,425 mechanical ventilation episodes.

Disclosures: Dr. Anderson reported receiving royalties from UpToDate, Online, and receiving research support from the CDC and the NIH/NIAID.

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Results underscore importance of patient participation

Dr. Vera DePalo

Dr. Vera DePalo, FCCP, comments: The results of this collaborative underscore an important point in patient-focused care, namely that participation of the patient in his or her own care is often able to accelerate a patient's recovery.

It seems that with a protocol for coordinated daily spontaneous awakening trials, patients were more likely to be able to have success with a spontaneous breathing trial. A more awake state enables the patient to have a stronger cough, do a better job of clearing secretions, and take deeper breaths.

In this study, these interventions resulted in a reduction in mechanical ventilator days, a reduction in ICU days, and a decrease in mean hospital length of stay. The partnership between patient, physician and care team has enhanced the care delivery and improved health in many chronic conditions. With the current focus on population health, engaging patients in improving their health will be a win for all. As care providers, we should continue to look for every opportunity to engage our patients to participate actively in their health care.

Dr. DePalo is CMO, Chief of Medicine, for Signature Healthcare Brockton Hospital in Brockton, MA.


 

References

PHILADELPHIA – A nurse- and respiratory therapist–led opt-out protocol for coordinated daily spontaneous awakening trials and spontaneous breathing trials was associated with significant reductions in hospital length of stay and ventilator-associated events in a multicenter quality improvement collaborative nested within a prospective study of ventilator-associated events.

The protocol led to significant increases – after adjustment for age, sex, Sequential Organ Failure Assessment score, reason for intubation, comorbidity score, and unit ID – in spontaneous awakening trials (SATs), spontaneous breathing trials (SBTs), and in the percentage of SBTs performed without sedation among 3,425 episodes and 22,991days of mechanical ventilation in the collaborative units, Dr. Deverick Anderson of Duke University Medical Center, Durham, N.C., reported at an annual scientific meeting on infectious diseases.

Dr. Deverick Anderson

Dr. Deverick Anderson

The SAT performance rate increased from 30% to 70% during the course of the study, and the SBT performance rate also increased, though more modestly, from about 55% to nearly 70%. The performance rate of SBTs performed with sedatives off – an intervention that improves the ability to be extubated – increased from nearly 55% to more than 95%.

The mean duration of mechanical ventilation decreased by 2.4 days, mean ICU stay decreased by 3 days, and mean hospital length of stay decreased by 6.3 days, Dr. Anderson said at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

Further, ventilator-associated conditions and infection-related ventilator-associated complications significantly decreased (odds ratio, 0.63 and 0.35, respectively). However, there was no decrease in possible or probable pneumonia (OR, 0.51).

Self-extubations increased (OR, 2.1, but there was no change in reintubations within 24 hours (OR, 0.96), Dr. Anderson said

“When we put all of this together, we were able to show a decrease in our rates of VAEs [ventilator-associated events] per 100 episodes. Over the course of the entire study, we calculated a 37% decrease in the risk of VAEs,” Dr. Anderson said.

However, the number of VAEs per 1,000 days didn’t change, because both the denominator and the numerator changed with the intervention. This finding raises questions about determining the right denominator to use. Based on the findings, it appears that ventilator episodes, rather than ventilator days, might be the best denominators, he said.

The study was conducted at 12 adult intensive care units at seven hospitals participating in the Centers for Disease Control and Prevention’s Prevention Epicenters Wake Up and Breathe Collaborative between November 2011 and May 2013. The collaborative was designed to prevent VAEs by decreasing patients’ sedative and ventilator exposures.

The collaborative was developed after early 2013 when the CDC replaced its ventilator-associated pneumonia (VAP) definitions with VAE definitions, expanding surveillance to VAEs in an effort to improve the objectivity of the definitions, to improve the ease of performing surveillance, and to try to improve the ability to make interhospital comparisons, Dr. Anderson explained, adding that VAEs include VAP, but also include pulmonary edema, atelectasis, and acute respiratory distress syndrome.

Thus, interventions aimed simply at reducing VAP may not change the rate of VAEs, he said.

Patients with VAEs stay on ventilators longer, stay in the ICU longer, are exposed to more antibiotic, and have two- to threefold increased rates of mortality, compared with those on ventilators but without VAEs, but little is known about preventing VAEs.

A larger study suggested that about a third of cases might be preventable, but no intervention has been tested and found to have an effect on the rate of VAEs. The Wake Up and Breathe Collaborative was tasked with answering the question of whether VAEs are preventable, and the investigators thought the best opportunity for prevention was to decrease the amount of sedation that ventilated patients received, Dr. Anderson said.

“More specifically – to decrease sedation through daily SATs and SBTs,” he added.

The opt-out protocol called for SATs and SBTs in all ventilated patients unless they met specific safety criteria or a physician wrote a specific opt-out order.

Though limited by the quasi-experimental open label study design, the findings are consistent with those from prior studies of such protocols.

“We felt that our multicenter prospective collaborative study was a success. … putting it all together, we conclude that VAEs are preventable when we improve compliance with evidence-based practice for our ventilated patients,” he said.Dr. Anderson reported receiving royalties from UpToDate and receiving research support from the CDC and the National Institutes of Health/National Institute of Allergy and Infectious Diseases.

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